Differentiating Between Those With True Pain And Those Seeking Pain Medication

A few years ago at our hospital, we were encouraged to attend lectures on the management of pain. Did you have a similar experience? We considered pain to be the fifth vital sign. If you were not properly treating pain and there was a perception that we were all undertreating it, you could be considered non-adherent and, in some instances, the dreaded word “malpractice” surfaced.

It subsequently occurred to me that the pendulum would swing the other way. We could be overmedicating the patients and granting their every wish to alleviate their “suffering” (a.k.a. pain). Let’s face it. It is easier to write that prescription for Percocet than to hear someone whine. Besides, can I truly get into patients’ skin and know how much pain they are having?  

I remember sitting there and reflecting on all those patients I thought were getting adequate treatment for pain. Looking back to a time earlier in my career, no one cried about excessive pain or even knew about the 10-point pain scale. Now almost everyone comes in and is able to tell you, without solicitation, how much pain they have on that infamous scale. Where did they learn about the scale? The highest pain I ever heard: “Doc, on a scale of 1 to 10, it’s a 100! What are you going to do for me, Doc?”

It is amazing, though, how there is not a set amount of pain for a particular procedure. How many times have you performed a Lapidus procedure and the patient took a few pain pills in comparison to a similar patient who had the same procedure and the prescription was barely controlling anything? How do you manage that patient?

So in our zest to treat pain, we may have inadvertently facilitated an addiction for many patients to that narcotic you and others have prescribed to make sure, as we were instructed, that we were properly managing their pain. Now what?

There are no easy answers. Sometimes it is easier to recognize a medication seeker. However, at other times, we are empathetic and do not want anyone to suffer.The pen then becomes mightier than the words “Not today.”  

As a great illustration to this perplexing dilemma, I saw a 55-year-old patient in the clinic 13 weeks after open reduction and internal fixation of a bimalleolar ankle fracture. His post-op course was unremarkable. That visit was to be his last. Objectively, the radiographs were fine, his range of motion was good and I could elicit no pain.

He appeared to be high as a kite. You know the punch line. “Doc, can I have a prescription for Percocet? My pain is 8 out of 10.” I had the chutzpah to tell him “No pills today.” I asked him what he took to be so high. “Why, Doc, I took three Percocets before I came in to help with my pain.”

What do you think happened? Saying no led to a scene with a lot of cursing. Who needs this?

A word of thanks to all those well-intentioned people who stridently admonished us for being soft on pain and making our patients suffer. Unfortunately, we have created a cohort of patients who rely on their pain medication to the point of having a problem. Additionally, people never want to experience any pain so they are quick to ask for something and will try to stay on pain medication longer. What is the next directive from on high?

Therefore, I encourage all of us to seek continuing education courses dealing with the management of pain. Also seek out peer-reviewed articles on this topic. Do not limit your reading to our own literature but broaden your search to the Journal of Bone and Joint Surgery, the Journal of the American Medical Association and the like.

“Numbing the pain for a while will make it worse when you finally feel it.” — J.K. Rowling, Harry Potter and the Goblet of Fire

Dr. Wallace is the Director of the Podiatry Service and the Medical Director of Ambulatory Care Services at University Hospital in Newark, N.J.

For further reading, see “Navigating Pain Management Prescriptions In Wound Care” in the January 2013 issue of Podiatry Today.

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